Quiet Mind, LLC
Michelle Roberts, FNP, PMHNP
1722 NW Raleigh St.  Suite 211  Mailbox 410
Portland, OR 97209
Phone: 971 . 282 . 2346
Fax: 971 . 228 . 1382 
Consent to Treatment 
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I acknowledge that I have spoken to the provider about the treatment I am considering.  All of my questions up to this point have been answered fully. 

I do hereby seek and consent to take part in the treatment by the provider named below. I understand that developing a treatment plan with this provider and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. 

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this provider. 

I am aware that I may stop my treatment with this provider at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment (For instance, no further prescription refills would be given if I elect to stop treatment with this provider). 

I know that I must call to cancel an appointment at least 48 hours (2 days) before the time of the appointment. If I do not cancel within the specified time frame and/or do not show up, I will be charged for that appointment. 

I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the provider may stop my treatment. 

My signature below shows that I understand and agree with all of these statements. 

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Signature of client (or person acting for client) 						Date 

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Printed name 													Relationship to client (if necessary) 

I, the provider, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person’s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. 

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Signature of provider											Date